Lack of Association Between Intraoperative Handoff of Care and Postoperative Complications

A Retrospective Observational Study

Vikas N. O'Reilly-Shah; Victoria G. Melanson; Cinnamon L. Sullivan; Craig S. Jabaley; Grant C. Lynde

Disclosures

BMC Anesthesiol. 2019;19(182) 

In This Article

Discussion

Our study demonstrated that anesthesia handoffs were associated with an increased rate of adverse events when examined in isolation. However, when accounting for all confounders, neither attending or complete handoffs of anesthesia care were associated with a composite measure of adverse postoperative outcomes. Comorbid conditions, case length, and case timing (i.e. evenings or weekends) were found to be important explanatory factors when examining the association between handoffs and adverse outcomes.

Given the complexity of perioperative care, attributing outcomes to any single intraoperative event, such as handoffs of anesthetic care, is problematic. Handoffs represent a potential entry point for error in patient care, and the Joint Commission estimates that 80% of serious medical errors involve failure of communication between caregivers.[16,17] Changes in care team members may also introduce heterogeneity in clinical care. Conversely, handoffs allow for rested personnel to assume care, heighten vigilance and performance, and therefore possibly mitigate these risks. Estimates of handoff effects have varied widely in prior investigations; however, estimates of their effect in larger, more robust investigations have been modest.[1,2,7,8] Effect estimates may therefore be influenced by sample size, case mix, and the relative balance of error introduction versus harm mitigation influenced by local practice.

Various structured tools have been proposed to mitigate the risk of communication lapses during handoffs.[18,19] In our healthcare system, a structured communication tool is available for the providers in the operating room, however handoffs occurring between providers outside the operating room do not have readily available checklists. While various studies have demonstrated improved retention of elements of the patient's care,[20,21] none have demonstrated differences in patient outcomes. One potential explanation for this is the immediate availability of the electronic medical record. Examining the patient's medical record is frequently the most common task that an incoming provider performs,[22] which mitigates communication lapses involving medication administration or pertinent past medical history. Another explanation could be the availability of structured communications tools, although implementation and use of these tools are highly context-dependent and with a great deal of potential variability in actual use.

Another potential explanation for the incongruity of our results with prior investigations may be that local practice patterns or experience surrounding handoffs and postoperative care can mitigate their potential harm. Our rates of attending-only and complete handoffs (21.3 and 10.9%, respectively) exceeded that of prior large investigations.[1,8,9] Differences in care team model, care team composition, or the conduct of handoffs may also influence their impact on clinical outcomes. Intraoperative handoffs may influence clinical outcomes by compromising the integrity of transitions to the post-anesthesia care unit (PACU) or intensive care unit through progressive knowledge loss. Our implementation of structured PACU handoffs or model of PACU care, with a dedicated attending anesthesiologist and trainee during daytime hours, may therefore mitigate the hypothetical negative impact of intraoperative handoffs.

Strengths of our study include congruence with the known literature. The explicitly performed analyses examining the impact of comorbid conditions, case length, and case timing, which are factors known to influence postoperative complications, yielded expected results. As noted by prior investigators, this type of investigation and analytic approach may be valuable means by which to assess the impact of local practice.[9] Similarly, the limited predictive ability of age and BMI in our model argue against overt residual confounding.

Our study has important limitations. Inherent to a retrospective, single-center study are the broad limitations that the work should be viewed as hypothesis-generating rather than hypothesis-testing, and that the results obtained from our center may not generalize to other contexts. In additionour sample size is based on the NSQIP sampling technique; although well-established, this may have served to introduce bias. NSQIP does not capture all potential clinical outcomes of interest, and not all outcomes are readily attributable to intraoperative anesthetic care. Surgical case volumes and types were heterogeneous, and although we attempted to adjust for surgical complexity, the strength of the observed association may vary within these categories. More broadly, residual confounding cannot be excluded despite appropriate sensitivity analyses. We conceptualized handoffs as being binary with respect to whether they occurred at the attending physician or entire anesthesia care team level. As such, our findings may not be comparable to prior studies utilizing stratified analyses of handoff counts. We did not account for the effect of staff breaks in our analysis because these may be inconsistently documented. While we utilize a structured handoff tool, we did not include this in our analysis because we were unable to assess utilization compliance. As previously discussed, local practice patterns regarding care team models and the conduct of handoffs are likely important but difficult to quantify, and therefore the generalizability of our findings to dissimilar settings is limited.

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